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Learning Charisma

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I entered university an accounting major.

My first year, I took all the recommended courses: accounting theory, fundamentals of financial and managerial accounting, and so on.

I’d likely be sitting in an office balancing company ledgers or completing tax documents had I never met Hal Miller.  A Harvard-educated professor, Dr. Miller taught multiple sections of the Psychology 111 course students could take as part of the required “general education” curriculum.

Decades have now passed since I first met him.  Still, I remember that first class as if it were yesterday.  When I arrived, every seat in the large, theater-style classroom was already taken, students overflowing into the hallway outside.  In time, I’d learn many were not officially registered for the class.  They were there because they wanted to hear him speak.Hal Miller

Within weeks, I’d changed my major to psychology.  I’m not sure how interested I was in the subject at the time.  Rather, I wanted to be like Hal Miller.  He loved what he was doing, was devoted to learning, and, most importantly, made me want to study.  He was, in a word, charismatic.

“Charisma,” researchers Antonakis, Fenley, and Liechti report, “is rooted in values and feelings.  It’s influence born of the alchemy that Aristotle called, the logos, the ethos, and the pathos.”  

LOGOS = WORDS, LOGIC, FACTS

ETHOS = ETHICS, CREDIBILITY, EXPERTISE

PATHOS =  EMOTIONS, CONNECTION, LIKE-MINDEDNESS

Hal Miller embodied all three qualities.  His ability to engage, communicate, and inform, literally changed my life.  I’m sure you can identify people who’ve had a similar impact on you.

But how did he do what he did?   Did he learn it?  Was it in his genes?

It turns out, the word, charisma, comes from the Greek χάρισμα, meaning “gift of grace” — a view widely held even today.  You either “got it or you ain’t.”

Curiously, while one study in psychotherapy found it to be both relationally and therapeutically helpful, most of the serious research on the subject comes from other fields where social influence is critical to success (e.g., leadership, training, management).  There, the evidence is clear: charisma is, “a learnable skill or, rather, a set of skills,” the potency of which can be dramatically improved with practice.

What exactly does that entail?

As a person whose spent his entire professional career providing continuing education workshops to therapists, I can tell you the absence of specific training means its mostly trial and error.  A few have the good fortune to work closely with a gifted practitioner or presenter.  I had the opportunity, or example, to work closely with Insoo Berg — a person who exuded warmth and charisma both in the therapy room and on the lecture circuit.  And yet, rarely are students of charismatic individuals are as successful or magnetic as their mentors.

So, what does it take?

As hackneyed as it may sound at first, the key is “being yourself.”  While its tempting to copy the content, style, and mannerisms of the Hal Millers and Insoo Bergs in our lives, doing so, everyone quickly recognizes, is mere tribute.  Success means putting the principles of charisma — logos, ethos, pathos — into practice in a way that is congruent with who you are, your own style, persona and, critically, message.

Below, you’ll find a TedTalk by Professor John Antonakis, one of the leading researchers on charisma.  It’s worth a listen.  The first 5 minutes is interesting and provocative, but you must listen longer to learn about the evidence documenting that you can dramatically improve your ability to communicate with impact.

If you still are looking for something more practical and skill-based, and specific to psychotherapy, then join my colleagues and I for the “Training of Trainers” workshop, held once every other year.  Together with an international faculty, and participants from around the world, we’ll work on helping you become the most effective version of you, either in your role as a therapist or trainer/presenter.

Finding Meaning in Psychotherapy Amidst the Trivia and Trivial

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I don’t know if you feel the same way I do.  Looking back, I’m pretty sure its been going on for a while, but somehow I didn’t notice.

Professional books and journals fill my bookshelves and are stacked around my desk.  I am, and always have been, a voracious–even compulsive–reader.  In the last couple of years, the volume of material has only increased–exponentially so, if I include digital items saved to my desktop.

Now, I’ll be the first to admit: it’s hard keeping up.  But that’s really not my problem.

The issue is: I feel like I’m drowning in trivia and the trivial.

How about you?  When was the last time you read something truly meaningful?

Increasingly, research journals are filled with studies that are either so narrow in focus as to defy any real world application, or simply revisit the same questions over and over.   Just how many more studies does the field need, for example, on cognitive-behavioral therapy?  A Google Scholar search on the subject, crossed with the term, “randomized controlled trial,” returns over a million hits!

In terms of translating research into practice, here’s a sample of articles sure to appeal to almost every clinician (and I didn’t have to “dig deep” to find these, by the way, as all were in journals neatly stacked on my desk):

  1. Psychodynamizing and Existentializing Cognitive-Behavioral Interventions
  2. How extraverted is honey.bunny77@hotmail.de? Inferring personality from e-mail addresses
  3. Satisfaction with life moderates the indirect effect of pain intensity on pain interference through pain catastrophizing

I didn’t make these up.  All are real articles in real research journals.  If you don’t believe me, click on the links to see for yourself.

Neologisms (#1) and cuteness (#2) aside, their titles often belie a mind-numbing banality in both scope and findings.  Take the last study.  Can you guess what its about?  Satisfaction with life moderates the indirect effect of pain intensity on pain interference through pain catastrophizing.  And what findings do you think the authors spent 10 double-column, 10-point font pages relating in one of psychology’s most prestigious journals?

“Satisfaction with life appears to buffer the effect of pain.”

Hmm.  Not particularly earth-shattering.  And, based on these results, what do the authors recommend?  Of course: “Further evaluation in longitudinal and interventional studies”  (I foresee another study on cognitive-behavioral therapy in the near future).

Purpose, belonging, sense-making, transcendence, and growth are the foundations of meaning.  Most of what shows up in my inbox, is taught at professionals workshops, and appears in scholarly publications has, or engenders, none of those qualities.  The cost to our field and the people we serve is staggering.  Worldwide, rates of depression, anxiety, and suicide continue to rise.  At the same time, fewer and fewer people are seeking psychotherapy–34% fewer according to the latest findings.  It is important to note that even when extensive efforts are made, and significant financial support is provided, 85% of those who could benefit choose not go.  I just can’t believe its because therapists haven’t attended the latest “amygdala retraining” workshop, or do not know how to “psychodynamize” their cognitive-behavioral interventions.

Have you heard of Dr. Ben Caldwell?  His book, Saving Psychotherapy: Bringing the Talking Cure Back from the Brink, speaks directly to the challenges facing the field as well as steps every clinician can take to restore meaning to both research and practice.  Take a listen to the interview below.

The Illness and the Cure: Two Free, Evidence-based Resources for What Ails and Can Heal Serious Psychological Distress

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Findings from several recent studies are sobering. Depression is now the leading cause of ill-health and disability worldwide–more than cancer, heart disease, respiratory problems, and accidents.  Yesterday, researchers reported that serious psychological distress is at an all-time high, significantly affecting not only quality but actual life expectancy.  And who has not heard about the opioid crisis?

The research is clear:  psychotherapy helps.  Indeed, its effectiveness is on par with coronary artery bypass surgery.  Despite such results, availability of mental health services in the U.S. and other Westernized nations has seriously eroded over the last decade.   Additionally, modern clinical practice is beset by regulation and paperwork, much of which gets in the way of treatment’s most important healing ingredient: the relationship.

What can practitioners do?

Completing paperwork together with clients during the visit–a process termed, “collaborative (or concurrent) documentation”–has been shown to save full-time practitioners between 6 and 8 hours per week, thereby improving capacity up to 20%.

It’s a great idea: completing assessments, treatment plans, and progress notes together with clients during rather than after the session. Unfortunately, it’s chief selling point to date seems to be that it saves time on documentation–as though filling out paperwork is an end in and of itself!  Clearly, the real challenges facing mental health services are getting people into and keeping them in care.   Here, the research literature is clear, people are more likely to stay engaged in care that is: (1) organized around their goals; and (2) works.  Collaborating on and coming to a consensus regarding the goals for treatment, for example, has the largest impact on outcome among all of the relationship factors in psychotherapy, including empathy!  Additionally, when documentation FITs the clients’ view of the process and is deemed transparent and respectful, trust–another essential ingredient of the therapeutic relationship–improves.

For the last several years, practitioners and agencies around the world have been using the ICCE “Service Delivery Agreement” and “Progress Note” as part of their documentation of clinical services.  Both were specifically designed to be completed collaboratively with clients at the time the service is provided and both are focused on documenting what matters to people in treatment.  Most important of all, however, both are part of an evidence-based process documented to improve engagement and effectiveness listed on SAMHSA’s National Registry of Evidence-based Programs and Practices.

If you’d like a copies for yourself, just email me at scottdmiller@talkingcure.com. 

The Replication Crisis in Psychology: What is and is NOT being talked about

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Psychology has been in the headlines a fair bit of late—and the news is not positive.  I blogged about this last year, when a study appeared documenting that the effectiveness of CBT was declining–50% over the last four decades.

The problem is serious.  Between 2012 and 2014, for example, a team of researchers working together on their free time tried to replicate 100 published psychology experiments and succeeded only a third of the time!  As one might expect, such findings sent shock waves through academia.

Now, this week, The British Psychological Society’s Research Digest piled on, reviewing 10 “famous” findings that researchers have been unable to replicate—despite the popularity and common sense appeal of each.  Among others, these include:

  • Power posing does not make you more powerful;
  • Smiling does not make you happier;
  • Exposing you to words (known as “priming”) related to ageing does not cause you to walk like an old person;
  • Having a mental image of a college professor in mind does not make you perform more intelligently (another priming study);
  • Being primed to think of money will not cause make you act more selfishly; and
  • Despite being reported in nearly every basic psychology text, babies are not born with the power to imitate.

Clearly, replication is a problem.  The bottom line?  Much of psychology’s evidence-base is built on a foundation of sand.

Amidst all the controversy, I couldn’t help thinking of psychotherapy.  In this area, I believe, the problem with the available research is not so much the failure to replicate, but rather an unwillingness to accept what has been replicated repeatedly.  Contrary to hope and popular belief, one—if not the most—replicated finding is the lack of difference in outcome between psychotherapeutic approaches.

It’s not for lack of trying.  Massive amounts of time and resources have been spent comparing treatment methods.  With few exceptions, either no or inconsequential differences are found.

Consider, for example, the U.S. Government spent $33,000,000 studying different approaches for problem drinking only to find what we already know: all worked equally well.  A decade later, the British officials spent millions of pounds on the same subject with similar results.

Just this week, a study was released comparing the hugely popular method called DBT to usual care in the treatment of “high risk suicidal veterans.”   Need I tell you what they found?

As the Ground-Hog-Day-like quest continues, another often replicated finding is ignored.  One of the best predictors of the outcome of psychotherapy is the quality of the therapeutic relationship between the provider and recipient of care.  That was one of the chief findings, for example, in both of the studies on alcohol treatment cited above (1, 2).  Put simply, better relationship = improved engagement and effectiveness.

Sadly, but not surprisingly, research, writing, and educational opportunities focused on the alliance lags model and techniques.  Consider this: slightly more than 55,000 books are in print on the latter subject, compared to a paltry 193 on the former.  It’s mind-boggling, really.  How could one of the most robust and replicated findings in psychotherapy be so widely ignored?

My colleague Daryl Chow is working hard to get beyond the “lip service” frequently paid to the therapeutic relationship.  In an an ongoing series of studies aimed at helping clinicians improve their ability to engage, retain, and help people in psychotherapy by targeting training to the individual practitioners strengths and weaknesses.  Not surprisingly, the results show slow and steady improvement in connecting with a broader, more diverse, and challenging group of clinical scenarios!

Why aren’t therapists talking about this?

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Turns out, every year, for the last several years, and right around this time, I’ve done a post on the subject of deterioration in psychotherapy.  In June 2014, I was responding to yet another attention-grabbing story published in The Guardian, one of the U.K.’s largest daily newspapers. “Misjudged counselling and therapy can be harmful,” the headline boldly asserted, citing results from “a major new analysis of outcomes.” The article was long on warnings to the public, but short on details about the study.  In fact, there wasn’t anything about the size, scope, or design.  Emails to the researchers were never answered.  As of today, no results have appeared in print.

One year later, I was at it again—this time after seeing the biopic Love & Mercy, a film about the relationship  between psychologist Eugene Landy and his famous client, Beach Boy Brian Wilson. In a word, it was disturbing.  The psychologist did “24-hour-a-day” therapy, as he termed it, living full time with the singer-songwriter, keeping Wilson isolated from family and friends, and on a steady dose of psychotropic drugs while simultaneously taking ownership of Wilson’s songs, and charging $430,000 in fees annually. Eventually, the State of California intervened, forcing the psychologist to surrender his license to practice.  As egregious as the behavior of this practitioner was, the problem of deterioration in psychotherapy goes beyond the field’s “bad apples.”

Do some people in therapy get worse? The answer is, most assuredly, “Yes.” Research dating back several decades puts the figure at about 10% (Lambert, 2010). Said another way, at termination, roughly one out of ten people are functioning more poorly than they were at the beginning of treatment. Despite claims to the contrary (e.g., Lilenfeld, 2007), no psychotherapy approach tested in a clinical trial has ever been shown to reliably lead to or increase the chances of deterioration. NONE. Scary stories about dangerous psychological treatments are limited to a handful of fringe therapies–approaches that have been never vetted scientifically and which all practitioners, but a few, avoid.

So, what is the chief cause of deterioration in treatment? Norwegian psychologist Jørgen A. Flor just completed a study on the subject. We’ve been corresponding for a number  of year as he worked on the project.  Given the limited information available, I was interested.

What he found may surprise you. Watch the video or click here to read his entire report (in Norwegian). Be sure and leave a comment!

Improving the Odds: Implementing FIT in Care for Problem Gamblers and their Families

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Quick Healthcare Quiz

What problem in the U.S. costs the government approximately $274 per adult annually?

If you guessed gambling, give yourself one point.  According to the latest research, nearly 6 million Americans have a serious gaming problem—a number that is on the rise.  One-third of the Nation’s adults visit a Casino every year, losing according to the latest figures an estimated 100 billion dollars.

Which problem is more common?  Substance abuse or problem gambling?

If you guessed the former, give yourself another point.  Problems related to alcohol and drug use are about 3.5 times more common than gambling.  At the same time, 281 times more funding is devoted to treating drug and alcohol problems.  In March 2014, the National Council on Problem Gambling reported that government-funded treatment was provided to less than one quarter of one percent of those in need.

Does psychotherapy work for problem gambling?

If you answered “yes,” add one to your score.  Research not only indicates that psychological treatment approaches are effective, but that changes are maintained at follow up.  As with other presenting problems (e.g., anxiety and depression), more therapy is associated with better outcomes than less.

What is the key to successful treatment of problem gambling?

If you answered, “funding and getting people into treatment,” or some variation thereof, take away three points!

So, how many points do you have left?  If you are at or near zero, join the club.

Healthcare is obsessed with treatment.  A staggering 99% of resources are invested in interventions.  Said another way, practitioners and healthcare systems love solutions.  The problem is that research shows this investment, “does not result in positive implementation outcomes (changes in practitioner behavior) or intervention outcomes (benefits to consumers).”  Simply put, it’s not enough to know “what works.”  You have to be able to put “what works” to work.

BCRPGP

Enter the BC Responsible and Problem Gambling Program—an agency that provides free support and treatment services aimed at reducing and preventing the harmful impacts of excessive or uncontrolled gaming.  Clinicians working for the program not only sought to provide cutting-edge services, they wanted to know if they were effective and what they could do to continuously improve.

Five years ago, the organization adopted feedback-informed treatment (FIT)—routinely and formally seeking feedback from clients regarding the quality and outcome of services offered.    A host of studies documents that FIT improves retention in and outcome of psychotherapy.  Like all good ideas, however, the challenge of FIT is implementation.

Last week, I interviewed Michael Koo, the clinical coordinator of the BCRPGP.  Listen in as he discusses the principles and challenges of their successful implementation.  Learn also how the talented and devoted crew achieve outcomes on par with randomized controlled trials in an average of 7 visits while working with a culturally and clinically diverse clientele.

As you’ll hear, implementation is difficult, but doable.  More, you don’t have to reinvent the wheel or do it alone.  When FIT was reviewed and deemed “evidence-based” by the Substance Abuse and Mental Health Services organization in 2013, it received perfect scores for “implementation, training, support, and quality assurance” resources.

Do you know Norman Malone? FIT, Grit, and Grace Personified

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norman maloneAt the tender age of 10, Norman Malone’s father attacked him and his two younger brothers with a hammer while they slept.  Their mother, drugged into unconsciousness by her husband the prior evening, found the children the next morning.  Each had suffered grave head wounds, but were alive.  Later, all would learn the senior Malone had taken his life shortly after the attack, throwing himself in front of a suburban train.

A long recovery followed, months spent in a hospital learning to walk again.  Despite steady and dramatic improvement, Norman never regained the use of his right hand.  With his single functioning hand, he spent the next seven decades following a dream he’d had since he was five: to become a concert pianist.

It has been a solitary journey throughout.  In his youth, kids made fun of his damaged skull.  Teachers and advisors consistently advised him to give up his quest, deeming it “ludicrous.” Thinking he must be “crazy,” they even sent him for a psychological evaluation.   Wittgenstein

Sustained and focused application, or “grit,” research indicates is key for achieving difficult goals.  Norman Malone is grit and grace personified.  He persisted, eventually meeting a willing teacher at the Chicago Musical College.  That teacher knew the story of another famous left-handed pianist, Paul Wittgenstein—brother of the celebrated philosopher, Ludwig—who following the loss of his right hand in World War 1, used his family’s wealth to commission Ravel, Prokofiev, and other famous composers to write music for him.

Last week, I had the opportunity to meet Norman Malone.  Now 78 years of age, he graciously accepted an invitation to play at my home for participants attending the ICCE Intensive Trainings.  Forty-five participants from around the world (US, Canada, the Netherlands, Sweden, Denmark, Finland, Australia) crowded into my living room.  You could hear a pin drop as he spoke.

It startedMalone at home with his story.  Then, he played—doing with one hand what many would think impossible with two.  When asked what drove him to continue in the face of so many challenges, he said, in a quiet yet confident voice, “Because there is so much to learn!”

You can get a taste of his performance and a watch a video of his life story, by clicking on the videos below.

Love, Mercy, & Adverse Events in Psychotherapy

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Just over a year ago, I blogged about an article that appeared in one of the U.K.’s largest daily newspapers, The Guardian.  Below a picture of an attractive, yet dejected looking woman (reclined on a couch), the caption read, “Major new study reveals incorrect … care can do more harm than good.”

I was interested.

As I often do in such cases, I wrote directly to the researcher cited in the article asking for a reprint or pre-publication copy of the study.  No reply.  One month later, I wrote again.  Still, no reply. Two months after my original email, I received a brief note thanking me for my interest in the study and offering to share any results once they became available.

“Wait a minute,” I immediately thought, “The results of this ‘major new study’ about the harmful effects of psychotherapy had already been announced in a leading newspaper.  How could they not be available?”  Then I wondered, “If there are no actual results to share, what exactly was the article in The Guardian based on?”

So-called “adverse events” are a hot topic at the moment.  That some people deteriorate while in care is not in question.  Research dating back several decades puts the figure at about 10%, on average (Lambert, 2010). When those being treated are adolescents or children, the rates ca be twice as high (Warren et al., 2009).

Putting this in context, compared to medical procedures with effect sizes similar to psychotherapy (e.g., coronary artery bypass surgery, stages II and III breast cancer, stroke), the rate is remarkably low. Nonetheless, it is a matter of concern–especially given research showing that therapists are not particularly adept at recognizing when those they serve deteriorate in their care (Hannan et al., 2005)

The question, of course, is the cause?

To date, whenever the question of adverse events is raised, two “usual suspects” are trotted out: (1) the method of treatment used; and (2) the therapist.  Let’s take a closer look at each.

In an October 2914 article published in World Psychiatry, Linden and Schermuly-Haupt wrote about estimates of side effects associated with specific methods of treatment that had been reported in an earlier study by Swiss researchers.  The numbers were shocking.  Patient reported “burdens caused by therapy” were 19.7% with CBT, 20.4% for systemically oriented treatments, 64.8% with humanistic approaches, and a staggering 94.1% with psychodynamic psychotherapy.

Based on such results, one could only conclude that anyone seeking anything other than CBT should have their head examined.

There is only one problem.  The figures reported were wrong.  Completely and utterly wrong.  Linden and Schermuly-Haupt made an arithmetic error and, as a result, totally misinterpreted the Swiss findings. Read the study for yourself.  When it comes to adverse events in psychotherapy, CBT–the fair-haired child of the evidence-based practice movement–is not better.  Indeed, as the study clearly shows, people treated with humanistic and systemic approaches suffered fewer “burdens” than expected, while those in CBT had a slightly higher, although not statistically significant, level. More, the observed percentage of people in care who perceived the quality of the therapeutic relationship–the single most potent predictor of engagement and outcome–as poor was significantly higher than expected in CBT and lower for both humanistic and systemic approaches.

How could the researchers have gotten it so wrong?

As I pointed out in my blog over year ago, despite claims to the contrary (e.g., Lilenfeld, 2007), no psychotherapy approach tested in a clinical trial has ever been shown to reliably lead to or increase the chances of deterioration.  NONE.  Scary stories about dangerous psychological treatments are limited to a handful of fringe therapies–approaches that have been never vetted scientifically and which all practitioners, but a few, avoid.  In short, its not about the method.

(By the way, over a month ago, I wrote to the lead author of the paper that appeared in World Psychiatry via the ResearchGate portal–a site where scholars meet and share their publications–providing a detailed breakdown of the statistical errors in the publication.  No response thusfar)

With only one suspect left, attention naturally turns to the therapist–you know, the “bad apple” in the bunch.  Here’s what we know.  That some practitioners do more harm than others is not exactly news. Have you seen the new biopic Love & Mercy, about the life of Beach Boy Brian Wilson?  You should.  The acting is superb.

Wilson’s therapist, psychologist Eugene Landy (chillingly recreated by actor Paul Giamatti), is a prime example of an adverse event.  See the film and you’ll most certainly wonder how the guy kept his license to practice so long.  And yet, as I also pointed out in my blog last year, there are too few such practitioners to account for the total number of clients who worsen.  Consider this unsettling fact: beyond the 10% of those who deteriorate in psychotherapy, an additional 30 and 50% experience no benefit whatsoever!

Where does this leave us when it comes to adverse events in psychotherapy?

Whatever the cause, lack of progress and risk of deterioration are issues for all clinicians and clients.   The key to addressing these problems is tracking progress from visit to visit so that those not improving, or getting worse, can be identified and offered alternatives.  It’s that simple.

Right now, practitioners can access two simple, easy-to-use scales for free at www.scottdmiller.com.  Both have been tested in multiple, randomized, clinical trials and deemed evidence-based by the Federal Substance Abuse and Mental Health Services Administration (SAMHSA).

Learning to use the tools isn’t difficult.  It costs nothing to subscribe to the International Center for Clinical Excellence and begin interacting with professionals around the world who are using the measures to improve the quality and outcome of behavioral health services.

P.S.: On the one year anniversary of my original email to the reseacher cited in the Guardian, I sent another.  That’s over a month ago.  So far, no reply.  By contrast, the reporter who broke the story, Sarah Boseley , wrote back within a half hour!  She’s following up her sources.  I’ll let you know if she gets a response.

Implementing Feedback Informed Treatment

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What do the Sydney Opera House, Boston Central Artery Tunnel, and Eurozone Typhoon Defense Project all have in common?   In each case, their developers suffered from, “The Planning Fallacy” (PF). First recognized in 1979 by Nobel Prize winning psychologists Daniel Kahneman and Amos Tversky, the planning fallacy is the all too human tendency to underestimate the amount of time and money projects will require for completion. The impact is far from trivial, especially if you are footing the bill. The Sydney Opera House, for example, took ten years longer and cost nearly 15 times more money than originally planned (102 versus 7 million). The tunnel project in Boston ran over budget to the tune of 12 billion dollars—a figure equivalent to 19,000 dollars for man, woman, and child living in the city!

Research documents that the same shortsightedness plagues implementation of new best practices in mental healthcare. In another post, I reviewed data indicating that between 70 and 95 percent of such efforts fail. The same body of evidence shows that prior experience with similar projects offers no protection. Indeed, regardless of experience, when planners are asked to provide a “best” and “worst” case estimate, the vast majority fail to meet even their most dire predictions.

The impact of a failed implementation on staff morale can be devastating—not to mention the waste of precious time and resources, and missed opportunity to provide more effective services to consumers. I’ve seen it first hand, had it whispered to me on breaks at workshops, as I crisscross the globe teaching about Feedback-Informed Treatment (FIT). At a workshop in Ohio, a woman approached me saying, “So, you are the guy that developed the Outcome and Session Rating Scales?” When I answered yes, she leaned in, and in a quiet voice, asked, “Will you be telling us how to use them? ‘Cause we’ve been using them at my agency for about a year, but no one knows what they’re for.” More recently, at a training on the west coast, a participant told me he and his colleagues started using the scales following a two- day workshop at his agency, but eventually stopped. “Initially, there was a lot of excitement,” he said, “We really bought in. All of us were all doing it, or at least trying. Then, it just kind of fizzled.” I nodded in recognition. The planning fallacy strikes again!

Since first being reviewed and listed on SAMHSA’s National Registry of Evidence Based Programs and Practices, interest in the proven approach to improving the outcome and retention of mental health services has exploded.  Many thousands of practitioners have downloaded the ORS and SRS.   Given the brevity and simplicity of scales, it is easy to assume that implementation will be quick and relatively easy. Ample evidence, as well as experience in diverse settings around the world, strongly suggests otherwise.

It goes without saying that getting started is not the problem.   Fully implementing FIT is another story. It takes time and careful planning—for most, between five and seven years. Along the way, there’s plenty of support to aid in success:

  • Managers, supervisors, and clinicians can join a free, online, international community of nearly 10,000 like-minded professionals using FIT in diverse settings (www.iccexcellence.com). Every day, members connect and share their knowledge and experience with each other;
  • The FIT Treatment and Training Manual is available to aid in planning, guiding progress, and identifying common blind spots in implementation; ,
  • The 2-day ICCE FIT Implementation workshop provides an in-depth, evidence-based training based on the latest findings from the field of implementation science. Over the last few years, we’ve learned a great deal about what leads to success. Immunize yourself against the planning fallacy by joining colleagues from around the world for this event.
  • Finally, there’s technology.  Three electronic systems for administering, scoring, and understanding the ORS and SRS are available to aid in implementation.  The video below introduces www.fit-outcomes.com, a simple, easy-to-use website with a clean, Apple-like interface that makes gathering and interpreting outcome and alliance data a snap.

What do clinicians want anyway?

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What topics are practitioners interested in learning about?

If you read a research journal, attend a continuing education event, or examine the syllabus from any graduate school course, you’re likely to conclude: (1) diagnosis; (2) treatment methods; and perhaps (3) the brain.  As I’ve written previously about, the brain is currently a hot topic in our field.

Ask clinicians, however, and you hear something entirely different.  That’s exactly what Giorgio Taska and colleagues did, publishing their results in a recent article in the journal, Psychotherapy.  Here’s what they found.

Regardless of age or theoretical orientation, the top three topics of interest among practicing clinicians were: (1) the therapeutic relationship; (2) therapist factors; and (3) professional development.

Let’s consider each one in turn.

Number one: the therapeutic relationship.  Honestly, when was the last time you attended a workshop focused solely on improving your ability to connect with, engage, understand, and relate to your clients?  The near complete absence of such offering is curious, isn’t it?  Especially when you consider that the quality of the therapeutic bond is the single best predictor of treatment outcome, the most evidence-based principle in the literature!

Paradoxically, research shows that therapists who are able to solicit negative feedback about the alliance early in the treatment process have better outcomes in the end.  Turns out, soliciting such feedback and using it to strengthen the working relationship is a skill fewclinicians–despite their beliefs to the contrary–possess.

There’s a simple solution: download and begin using the Session Rating Scale, a simple, four-item alliance measure designed to be administered at the end of each session.   Multiple, randomized clinical trials now show that formally seeking client feedback not only improves outcome but decreases both drop out and deterioration rates.

Number two: therapist factors.  In other words, you!

Some time ago, veteran psychotherapy researcher Sol Garfield–one of the editors of the prestigious Handbook of Psychotherapy and Behavior Change–called the therapist the “neglected variable” in psychotherapy research.  Available evidence documents that the clinician doing the therapy contributes 5 to 9 times more to outcome than the method used.

Which brings us to topic number three: professional development.

Large, multinational studies document the central importance that professional development plays in the identity and satisfaction of clinicians.  And yet, as I wrote not long ago, “the near ubiquitous mandate that clinicians attend so many hours per year of approved ‘CE’ events in order to further their knowledge and skill base has no empirical support.”  So, what does work?  Recent research by Singapore-based psychologist Daryl Chow shows that the best invest 4.5 more hours outside of work engaged in activities specifically aimed at improving their performance than their average counterparts–an process known as deliberate practice.

Therapist Wanted: Dead or Alive

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Do you get those letters about the top healthcare providers in your area?

At the beginning of the new year, our city’s local magazine publishes a list of the top healthcare providers.  It’s a big deal.  Organized by location and specialty, the issue contains full-page photos, glossy spreads, and breezy write-ups.  Impressive stuff with a wide and hungry readership anxious to sort the best from the rest.

So, how do the publishers separate the proverbial “wheat from the chaff?”  The answer, depending on whether you are a provider or potential patient, may alternately surprise or frighten you.

Not long ago, Abigail Zuger received one of those letters.  In it, she learned that a relative of hers had been named “one of the worlds top physicians in his area of expertise.”   Ordinarily, she would have been proud.  There was only one problem.  Her now esteemed relative was dead–and not just recently.  He’d been dead 16 years!

Abigal Zuger is a physician and professor of medicine at Columbia University.  The story about her experience appeared in the New York Times.  In it, she notes the temptation to become cynical, to dismiss the Top Doc lists, “as just so much advertisement and avarice.”  She concludes, however, that a “more nuanced and charitable view is…[that] these services may simply be trying, valiantly if not clumsily, to remedy the single biggest mystery in all of health care…what makes a top doctor…[and] how to find one.”

Three methods dominate among list makers: (1) culling names and addresses from phone directories; (2) polling healthcare providers; and (3) collating patient online ratings.  Said another way, consulting available lists lets you know if your healthcare provider once had a phone, was liked by their colleagues, or managed not to piss off too many of the people they treated!

Remarkably absent from the criteria used to identify top providers is any valid and reliable measure of their effectiveness!

Determining one’s effectiveness as a mental health professional is not as difficult or time consuming as it was not long ago.  Whether you work with individuals, groups, or families, in inpatient, residential, or an outpatient setting, a simple set of tools is available for monitoring both the outcome and the quality of the services you provide.  The tools take minutes to administer and score and are free.

If you are worried about statistics, don’t be.  A variety of electronic solutions exist which not only will administer and score the measures but provide normative comparisons for assessing individual client progress and sophisticated analyses of provider, program, and agency effectiveness levels.

To see what’s possible, check out the Colorado Center for Clinical Excellence.  There, clinicians not only measure their effectiveness, but set benchmarks for superior performance and report clinician outcomes transparently on the agency website.

Dinner with Paul McCartney (and others)

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Growing up, my family had a game we frequently played around the dining room table.  “If you could invite anyone to dinner,” it always started,”who would it be?”  Invariably, my father chose historical figures: Abraham Lincoln, Mark Twain, Leonardo Da Vinci.  My mom was more inclined toward the living: Jackie O., J.D. Salinger, Lucille Ball.  My brothers, Marc and Doug, usually went for sports figures.  I recall Wilt Chamberlain and Willie Mays being popular choices–although there were many others whose names I’ve now forgotten.

Me?  Always the same answer: Paul McCartney.

Of course, the “name game” didn’t end there.  Whatever your choice, you also had to state why.  Here, my answer didn’t vary either.  “He’s one of the Beatles!” I’d say, frustrated whenever my family acted as though my statement needed further clarification.

To this date, I’ve never had a chance to met much less have dinner with Paul McCartney.  Seen him in concert a number of times but always from a distance.  Last week, however, I did have the opportunity to meet and spend time with a number of my heroes from the field of psychotherapy–and go to dinner together, not once, but twice!

We were together at the first ever Calgary Counseling Center Outcomes conference.  Thanks to Center’s director, Dr. Robbie Wagner, a small group of practitioners, policy makers, and agency managers were invited to spend two, intimate days learning from the field’s leading thinkers and researchers.  The Beatles of outcome research: Michael J. Lambert, Bruce E. Wampold, Michael Barkham, Wolfgang Lutz, and Gary Burlingame.  I presented the latest results on our studies of top performing therapists.

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It was every bit a rock concert–exciting, controversial, and cutting edge.   Below, I summarize the “greatest hits.”  I’ve also included the slides from each presentation for those who like to read the details contained in the “liner notes!”

Let me know what you think…here goes:

  • The burden born by people with mental health problems is second only to cancer (Depression alone results in a 70% loss of productivity)

Bottom line: People need the skills mental health professional have to offer

  • Treatment is effective. However, therapists believe they help far more people than they do (85% versus 20%);
  • Approximately 10% of adults deteriorate in care;
  • Between 14 and 25% of children are worse off following treatment;
  • Serious deterioration recognized in only one-third of cases;

Bottom Line: Mental health professionals overestimate their effectiveness and miss deterioration

  • Multiple, sophisticated, real world studies find no difference in outcome between people treated with different therapeutic approaches;
  • Factors related to the therapeutic relationship (i.e., empathy, collaboration, affirmation, genuineness) have a far greater impact on outcome (7:1) than treatment approach, adherence to treatment protocol, or rated competence.

Bottom Line: The pathway to improved effectiveness is not adopting new treatment approaches

  • Rapid and dramatic change (first 5 visits) occurs in as many as 40% of people and is maintained at two year follow up;
  • 90% chance of failure if there is no change between the 2nd and 8th visit;
  • As many as 25% of people remain in treatment while experiencing no measurable benefit;

Bottom Line: A large number of people need very little treatment to achieve lasting benefit

  • Separating intake from treatment results in higher drop out, lower and longer treatment response, and higher costs;

Bottom Line: Any barrier to establishing a relationship with a specific provider has a negative impact on outcome

  • The majority of individual practitioners are effective;
  • Around 16% of practitioners achieve outcomes significantly below average;
  • Less effective practitioners rate empathic understanding more highly as a professional/personal attribute than more effective practitioners;
  • The clients of the least effective clinicians were assigned to average practitioners, an additional 15% of clients would achieve clinical recovery;
  • Around 16% of practitioners consistently achieve outcomes significantly above average;
  • More effective practitioners rate resilience and mindfulness more highly as a professional/personal attribute;
  • Professional self-doubt and an “error-centric attitude” are associated with better outcomes.

Bottom Line: Choose your therapist carefully as they determine the outcome of care

  • When therapists receive feedback that clients are deteriorating, they: discuss it with clients about 60% of the time; make efforts to assist with other resources about 27% of the time; adjust therapeutic interventions 30% of the time; vary intensity or dose of services 9% of the time; consult with others (supervision, education, etc.) 7% of the time;
  • Therapist attitude toward soliciting and using feedback vary and influence results;
  • Therapists who value feedback achieve better outcomes;
  • Professional self-doubt and an “error-centric attitude” are associated with better outcomes;

Bottom Line: Regular, formal feedback from clients to therapists improves outcomes (as long as the therapist listens and acts on the feedback)

  • When asked, 92% of clients say they like the use of outcome measures in care.

Bottom Line: An overwhelming majority of clients endorse progress monitoring or providing feedback

How to double client outcomes in 18 seconds (Lambert, 2014)

Practice-based Evidence (Michael Barkham, 2014)

How to Improve Quality of Services by Integrating Common Factors into Treatment Protocols

When & How do Patients Change? Wolfgang Lutz Outcome Presentation

Reach: Pushing Your Clinical Effectiveness to the Next Level

Is Documentation Helping or Hindering Mental Health Care? Please Let me know.

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So, how much time do you spend doing paperwork?  Assessments, progress notes, treatment plans, billing, updates, etc.–the lot?

When I asked the director of the agency I was working at last week, it took him no time to respond. “Fifty percent,” he said, then added without the slightest bit of irony, “It’s a clinic-wide goal, keeping it to 50% of work time.”

Truth is, it’s not the first time I’ve heard this figure.  Wherever I travel–whether in the U.S. or abroad–practitioners are spending more and more time “feeding the bureaucratic beast.”  Each state or federal agency, regulatory body, and payer wants a form of some kind.  Unchecked, regulation has lost touch with reality.

Just a few short years ago, the figure commonly cited was 30%.  In the last edition of The Heart and Soul of Change, published in 2009, we pointed out that in one state, “The forms needed to obtain a marriage certificate, buy a new home, lease an automobile, apply for a passport, open a bank account, and die of natural causes were assembled … altogether weighed 1.4 ounces.  By contrast, the paperwork required for enrolling a single mother in counseling to talk about difficulties her child was experiencing at school came in at 1.25 pounds” (p. 300).

Research shows that a high documentation to clinical service ratio leads to higher rates of:

  • Burnout and job dissatisfaction among clinical staff;
  • Fewer scheduled treatment appointments;
  • No shows, cancellations, and disengagement among consumers.

Some potential solutions have emerged.  “Concurrent ,” a.k.a., “collaborative documentation.”  It’s a great idea: completing assessments, treatment plans, and progress notes together with clients during rather than after the session.  We started doing this to improve transparency and engagement at the Brief Family Therapy Center in Milwaukee, Wisconsin back in the late 1980’s.  At the same time, it’s chief benefit to date seems to be that it saves time on documentation–as though filling out paperwork is an end in and of itself!

Ostensibly, the goal of paperwork and oversight procedures is to improve accountability.  In these evidence-based times, that leads me to say, “show me the data.”  Consider the wide-spread practice–mandate, in most instances–of treatment planning. Simply put, it is less science than science fiction.  Perhaps this practice improves outcomes in a galaxy far, far away but on planet Earth, supporting evidence is spare to non-existent.  Where is the evidence that any of the other documentation improves accountability, benefits consumers, or results in better outcomes?

Put bluntly, the field needs an alternative.  What practice not only insures accountability but simultaneously improves the quality and outcome of behavioral health services?  Routinely and formally seeking feedback from consumers about how they are treated and their progress.

Soliciting feedback need not be time consuming nor difficult.  In 2013, two brief, easy-to-use scales were deemed “evidence-based” by  the Substance Abuse and Mental Health Services Administration (SAMHSA).  The International Center for Clinical Excellence received perfect scores for the materials, training, and quality assurance procedures it makes available for implementing the measures into routine clinical practice:

SAMHSA 1

SAMHSA 2

Then again, these two forms add to the paperwork already burdening clinicians.  The main difference?  Unlike everything else, numerous RCT’s document that using these forms increases effectiveness and efficiency while decreasing both cost and risk of deterioration.

How not to be among the 70-95% of practitioners and agencies that fail

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Our field is full of good ideas, strategies that work.  Each year, practitioners and agencies devote considerable time and resources to staying current with new developments.  What does the research say about such efforts?  When it comes to the implementation of new, evidence-based practices, traditional training strategies routinely produce only 5% to 30% success rates.  Said another way, 70-95% of training fails (Fixsen, Blase, Van Dyke, & Metz, 2013).  

In 2013, Feedback Informed Treatment (FIT)–that is, formally using measures of progress and the therapeutic alliance to guide care–was deemed an evidence-based practice by SAMHSA, and listed on the official NREPP website.  It’s one of those good ideas.  Research to date shows that FIT as much as doubles the effectiveness of behavioral health services, while decreasing costs, deterioration and dropout rates. 

As effective as FIT has proven to be in scientific studies, the bigger challenge is helping clinicians and agencies implement the approach in real world clinical settings.  Simply put, it’s not enough to know “what works.”  You have to be able to put “what works” to work.  On this subject, researchers have identified five, evidence-based steps associated with the successful implementation of any evidence-based practice.  The evidence is summarized in a free, manual available online.  You can avoid the 70-95% failure rate by reading it before attending another training, buying that new software, or hiring the latest consultant.

At the International Center for Clinical Excellence, the research on implementation is integrated into all training events as well as The Feedback Informed Treatment and Training Manual.  Based on the scientifically-established steps, clinicians, supervisors, and agency directors learn how to both plan and execute a successful implementation of this potent evidence-based practice. 

Do you do psychotherapy?

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You know psychotherapy works. Forty years of research evidence backs up your faith in the process. And yet, between 1998 and 2007, psychotherapy use decreased by 35%.  People still sought help, they just went elsewhere to get it.  For instance, use of psychotropic drugs is up 40% over the last decade.

A recent article in Popular Science traced the decline and outlined 3 provocative steps for saving the field. If you provide psychotherapy, it’s worth a read. The article is dead serious when recommending:

1. It’s time to GO BIG;

2. Getting a cute commercial; and

3. Dropping the biology jargon.

You’ve got to admit that the field’s fascination with biology is curious. A mountain of evidence points instead to the relationship between the provider and recipient of care. Other research shows that psychotherapy promotes more lasting change, at less cost and with fewer side effects than medication.

How to get the message out?

Many people and organizations are making a valiant effort. Ryan Howe almost single-handedly established September 25, as National Psychotherapy Day.  The American Psychological Association published a rare, formal resolution on the efficacy of psychotherapy.

Frankly though, the best commercial for psychotherapy is our results. Consider the approach taken by the Colorado Center for Clinical Excellence. They don’t merely cite studies supporting psychotherapy in general, they report their actual results!

You can begin doing the same by downloading two free, simple to use measures here.

Then, learn how to use the scales by reading the latest edition of the FIT Treatment and Training Manual.  In it, you’ll also learn how to use the data to improve both the quality and outcome of your services.

Resources on Feedback-Informed Treatment, Training, & Research

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Last week, I spent a day in London working with the clinical staff of the Hertfordshire Partnership NHS Foundation Trust.  The subject?  Feedback, of course!  As soon as I stepped off my transcontinental flight, I knew it was going to be a fun day.  Every way I turned at the Heathrow airport I was greeted by a machine asking for feedback about my experience: after exiting customs, at the baggage claim area, at the duty free shops.  Amazing!

The process was as engaging as it was efficient.  Tell us about your experience…by pressing a button bearing one of four different faces.  The similarity to the ICCE Young Child Outcome Rating Scale was striking (to say the least).  I felt compelled to register my feedback at every opportunity.

From London, I travelled to Gotheburg, Sweden for the first Scandanavian Advanced Intensive Training in Feedack Informed Treatment.  The event, organized by GCK, Gothenburg’s Center for Competence Development, sold out in a week with participants coming from all over Scandanavia.  I taught the course together with ICCE Senior Associate Susanne Bargmann using a curriculum based on the FIT Treatment and Training Manuals.  The series was developed to support, in part, ICCE’s application to the US Substance Abuse and Mental Health Services Administration (SAMSHA) for designation of FIT as an evidence-based practice.  Together with the Training of Trainers (TOT) and Supervision Intensive workshops, the manuals and Advanced Intensive training provides participants with the latest, cutting-edge, evidence-based information and skills in FIT.

Back in October, I blogged about an article that reviewed the evidence regarding psychotherapy training.   In it, the author John Malouff concluded, “There appears to be no evidence that coursework and research completion…have any value to future psychotherapy clients…”.  He continued, “Training programs…carry the responsibility to show that the training they provide have positive benefits for future clients.”

Well…on that score, learning FIT, available evidence shows, leads to direct benefits to consumers of behavioral health services.  Together with New Zealand based psychologist and ICCE Senior Associate Eeuwe Schuckard, I’ve updated the review of the research supporting FIT practice (click here).

Don’t wait to learn about or deepen your understanding of and skills in feedback informed treatment.  The Advanced Intensive scheduled for March 18-321st has a few spots left.  You can register online by clicking here.

By the way, shortly after the publication of Malouff’s review in Psychotherapy in Australia, I wrote to the editor, Liz Sheehan, and asked for permission to reprint the article.  Click here to read it.

Curing Clinician Overconfidence: Try Darting and Frowning

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Overconfidence.  It’s a problem that leads to systematic errors in judgement.   Long thought to arise out of hubris or the corrupting effects of the emotion, the evidence actually shows it to be built into humans’ evolved cognitive machinery.  Existimo ergo certus sum (I think, therefore I am…certain).

Behavioral health professionals are not immune.  A recently published study by Walfish, McAlister, O’Donnell, and Lambert (2012) asked clinicians how their effectiveness rates compared to other professionals.  Turns out, clinicians, on average, believed their results were better than 80% of their peers.  Not a single practitioner surveyed viewed themselves as below average and a full quarter (25%) thought they fell at the 90th percentile or higher in skill level and effectiveness!

It’s true that we are not alone in this tendency.  As indicated above, it’s how our brains work.  The typical driver, for example, believes themselves to be better than 80% of others on the road.  University professors, it appears, suffer from the most inflated levels of self-esteem, ranking themselves at the 94th percentile on average.

When it comes to learning, the consequences are significant.  Why change, after all, if you’re already pretty darn good and if the real problem is obvious: other drivers, poor students, etc., difficult life circumstances or the complex nature of some mental disorders?

Researchers have discovered a relatively simple solution to overconfidence: frowning.  That’s right.  Turning that smile upside down short circuits our reptilian wiring, making us more analytical and vigilant in our thinking, in the process enabling us to “question stories that we would otherwise unreflectively accept as true because they are facile and coherent” ( Holt, 2011).

What else can clinicians do?  Do something to gain perspective.  Take on another, divergent point of view, for example.  Practically speaking, scan rather than fix your gaze.  Literally, move your eyes.

Everyone has heard of “tunnel vision.”  Turns out, despite pledges to remain open and flexible, it ain’t so easy.  If you don’t agree, try a little experiment.    Fix your eyes on the flashing red and/or green dot at the center of the graphic and notice what happens to the surrounding yellow ones.  Be patient if the image hasn’t loaded.  It can take a minute or two.

They either blinked on and off or disappeared completely.  Interesting enough but here’s what’s really strange: the yellow dots actually never disappear.  They are always there despite what you see.  And no, the computer did not scan your visual field and cause the yellow dots to blink.  Neither is this an optical illusion.  Once again, it’s the way we are wired.  We think we are seeing everything…but we are not.  The result: overconfidence.  It’s why, following an automobile accident, people will say, “the other driver came out of nowhere.”  It’s why surgeons leave sponges inside their patients or miss seeing bleeds or small nicks of the scalpel.  It’s also why behavioral health practitioners routinely fail to detect deterioration and people at risk for dropping out of services (Hannan, et al. 2005).

Now, look again.  This time, however, shift your eyes about while watching the flashing dot in the center.  In other words, don’t fix your gaze.  If that doesn’t change what you see, then step back from the image and view it from a distance.  There, see!  The yellow dots are present the entire time.

Helping busy practitioners step back, shift their gaze, and otherwise improve their critical faculties and skills is the mission of ICCE.  Members connect, learn from, and share with the largest online community of mental health professionals in the world.  Thousands of members, hundreds of discussion forums, a massive and every growing library of research and other supportive documents, and how-to videos are available for free 24-7-365.

Many of the members and associates will be meeting in Amsterdam, Holland for the Achieving Clinical Excellence conference on May 16-18th.  Conference coordinator, Liz Pluut, has organized an line-up of international speakers, researchers, and practitioners that is guaranteed to push your clinical performance to the next level!  Participants are coming from all over Europe, the US, Canada, Asia, Australia, and more.  Don’t wait to register.  Space is limited and the response has been amazing.

OK, here’s something fun.  Take a look at the video below.  Oh yeah, make sure you smile and keep your eyes fixed on my hands!

Psychotherapy Training: Is it Worth the Bother?

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Big bucks.  That’s what training in psychotherapy costs.  Take graduate school in psychology as an example.  According to the US Department of Education’s National Center (NCES), a typical doctoral program takes five years to complete and costs between US$ 240,000-300,000.00.

Who has that kind of money laying around after completing four years of college?  The solution? Why, borrow the money, of course!  And students do.  In 2009, the average amount of debt of those doctoral students in psychology who borrowed was a whopping US$ 88,000–an amount nearly double that of the prior decade.  Well, the training must be pretty darn good to warrent such expenditures–especially when one considers that entry level salaries are on the decline and not terribly high to start!

Oh well, so much for high hopes.

Here are the facts, as recounted in a recent, concisely written summary of the evidence by John Malouff:

1. Studies comparing treatments delivered by professionals and paraprofessionals either show that paraprofessionals have better outcomes or that there is no difference between the two groups;

2. There is virtually no evidence that supervision of students by professionals leads to better client outcomes (you should have guessed this after reading the first point);

3. There is no evidence that required coursework in graduate programs leads to better client outcomes.

If you are hoping that post doctoral experience will make up for the shortcomings of professional training, well, keep hoping.  In truth, professional experience does not correlate often or significantly with client therapy outcomes.

What can you do?  As Malouf points out, “For accrediting agencies to operate in the realm of principles of evidence-based practice, they must produce evidence…and this evidence needs to show that…training…contribute(s) to psychotherapy outcomes…[and] has positive benefits for future clients of the students” (p. 31).

In my workshops, I often advise therapists to forgo additional training until they determine just how effective they are right now.  Doing otherwise, risks perceiving progress where, in fact, none exists.  What golfer would buy new clubs or pursue expensive lessions without first knowing their current handicap?  How will you know if the training you attend is “worth the bother” if you can’t accurately measure the impact of it on your performance?

Determining one’s baseline rate of effectiveness is not as hard as it might seem.  Simply download the Outcome Rating Scale and begin using it with your clients.  It’s free.  You can then aggregate and analyze the data yourself or use one of the existing web-based systems (www.fit-outcomes.com or www.myoutcomes.com) to get data regarding your effectiveness in real time.

After that, join your colleagues at the upcoming Advanced Intensive Training in Feedback Informed Treatment.   This is an “evidence-based” training event.  You learn:

• How to use outcome management tools (e.g., the ORS) to inform and improve the treatment services you provide;

• Specific skills for determining your overall clinical success rate;

• How to develop an individualized, evidence-based professional development plan for improving your outcome and retention rate.

There’s a special “early bird” rate available for a few more weeks.  Last year, the event filled up several months ahead of time, so don’t wait.

On another note, just received the schedule for the 2013 Evolution of Psychotherapy conference.  I’m very excited to have been invited once again to the pretigious event and will be bring the latest information and research on acheiving excellence as a behavioral health practitioner.  On that note, the German artist and psychologist, Andreas Steiner has created a really cool poster and card game for the event, featuring all of the various presenters.  Here’s the poster.  Next to it is the “Three of Hearts.”  I’m pictured there with two of my colleagues, mentors, and friends, Michael Yapko and Stephen Gilligan:

Thomas Szasz, M.D.: Memories of a Friend and Mentor

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Very early in the morning of December 9th, 2009, I received a call in my hotel room.  My long time colleague and mentor, Jeffrey Zeig was on the other end.

“May I ask you a favor?” he said.

“Of course,” I instantly replied, completely unaware of what was coming.

“Tom Szasz is caught in a snow storm and hasn’t been able to get out of New York, do you think you could fill in for him?  He was scheduled as a discussant for a presentation today being given by Otto Kernberg.”

Otto Kernberg?  I thought to myself.  The Otto Kernberg?  The psychoanalyst and professor of psychiatry at Cornell?  The author of…

“Oh my,” I replied, without thinking.

“It’s scheduled for around 4 this afternoon in the Anaheim Convention Center Arena.”

The big room?! I instantly thought, my panic rising.

“Oh my,” I once again replied, and then after a brief pause, answered, “Sure.”

“Thanks so very, very much Scott,” Jeff said, “you are a life saver.”

With that, I hung up the phone.  Sitting on the bed, I thought about Tom Szasz.  We’d met for the first time four years earlier at the same conference, The 2005 Evolution of Psychotherapy.  That’s when the photo of the two of us together was taken.  He was sitting at a table, eating breakfast alone, in the executive lounge at the conference hotel.  All the other places were occupied.  Of course, I knew who he was.  I’d read all of his books, a number more than once.  I’d also been to a number of presentations he’d given over the years.  Whether one agreed with his positions or not, you had to be awed by his careful, clear, and deliberate thinking.  On more than one occasion I’d seen him ensnare and then dispatch detractors with ease.

When I asked if I could sit at this table, he was instantly friendly.  “But of course,” he replied, his Hungarian accent immediately familiar to me.  For the next half hour, we talked, although not exclusively, mostly about the current state of the field of mental health.  I was struck by how many questions he asked me: where I was from, what I did, and especially about my work on top performing therapists.  Thereafter, we met every morning for breakfast.  It is a memory I cherish.

Once more, I find myself thinking about Dr. Szasz, who passed away at the age of 92 earlier this month. He authored over 30 books and 1000 articles.  As a lifelong libertarian, he argued consistently against what he considered instrusions on the freedom and dignity of individuals treated in the mental health system.  His work was often misunderstood and mischaracterized by people in and out of the profession, including the frequent association of his work with the anti-psychiatry movement (a movement he ridiculed, by the way, labelling it “quackery squared”).

For these, and many other reasons, personal and professional, I will miss him.  If you are not familiar with his work and thinking, the video below will give you a good introduction.  I promise you will be moved.

One final note.  The presentation by Otto Kernberg and my response certainly generated some fireworks (you can listen by clicking: Kernberg).  Given the short notice, tt had not been possible for to prepare in any meaningful way.  I did not have a chance to read the speech prior to hearing it.  As I listened, I took careful notes, and then, with Dr. Szasz in mind, did my level best to develop a thougtful, rational response based on my core values.  I pointed to recent research–an area I did know something about–which found Kernberg’s approach less effective than alternative approaches.  Needless to say, this led to a demand by Dr. Kernberg to respond.  The resulting back and forth between the two of us was exhilirating.  I hope Dr. Szasz would have been proud.

 

REACHing the Next Level of Clinical Performance: What it Really Takes

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Do any of these people look familiar?  Well, of course, I’m the guy in the middle pointing.  To my left is the rock and roll guitarist Joe Walsh.  On my right is world-renowned, card mechanic Richard Turner.  Why have I pictured myself sandwiched between these two?  Because they are both inspiring examples of what can be accomplished when individuals push beyond the “tried and true,” to reach the next level of performance.

Back in June, I read an article about Joe Walsh in the Chicago Tribune.  Buried deep in the piece was a brief biography of the guitarist that exemplifies what it takes to achieve excellence.  Walsh, who is 67 years old, began playing back in the late 1960’s.  Like many of his generation, he was inspired by the Beatles.  One day, he was listening to the band’s song, “And Your Bird can Sing,” which contains a “ridiculously finger stretching George Harrison guitar solo.”  According to the article, Walsh worked tirelessly until he mastered the riff.  It was only years later, long after he’d become famous, that he met Ringo Starr.  Walsh related the story to the drummer who “looked at Walsh like he was nuts.”  Harrison, Ringo told him, had played two guitar parts separately and tracked them on top of each other and later tracked them together in the studio.

Good thing no one told Walsh the truth.  As a result, he did what no one–even now–thought posssible.

On to Richard Turner.  Unless you are into magic or gambling, this may be the first time you’ve ever heard of this person.  Author Alex Stone, in his phenomenally fun and informative book, Fooling Houdini, describes him as “a card handler without equal, a man whose prowess with a deck borders on the supernatural.”  The supernaturnal?  Really?  I would have deemd such praise so much more hype, typical of “hollywood” and the media, if I hadn’t meet Turner personally and seen him work.  Simply put, there’s nothing he can’t do with a deck of cards.

Watch the brief video below filmed at this year’s “Training of Trainers” event in Chicago.  At all training events, we bring in top performers to entertain, inspire, and inform participants about what it takes to achieve excellence.

Not bad eh?  Especially when one considers that Turner is blind.  And the video above is only the tiniest snippet of his performance.  At one point, he dealt out hands of poker and black jack, asking audience members which position they would like to have dealt the winning cards.  Sure enough, whatever position was called, luck struck there and only there.  “Give me a number between 1 and 52,” he asked.  Whatever number was called out, he cut the cards to that exact position in the deck.  Did I mention he’s also a 6th degree black belt?  Simply put, Turner is a performer that is always pushing the limits.  Once he was cited for a driving motor cycle while blind!  How does he do it?  Practice.  Yep, seventeen hours a day!  For years, he slept with a deck of cards.  Like Walsh, he persisted until he mastered moves that no one considered possible or, more accurately, no one ever even imagined.

So, what can mental health professionals do to REACH the next level of clinical performance?  Over the last few years, together with my colleagues, we’ve been writing about the steps thrapists can take to achieving excellence.  This year, I was privileged to summarize the current state of the research on the subject in a keynote address at the Psychotherapy Networker conference in Washington, DC.  Here, for the first time, is “Part 1” of that address (the second half will follow soon).  In it, I lay out what the evidence says it takes to excel.

Feedback Informed Treatment: Update

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Chicago, IL (USA)

The last two weeks have been a whirlwind of activity here in Chicago.  First, the “Advanced Intensive.”  Next came the annual “Training of Trainers.”  Each week, the room was filled to capacity with practitioners, researchers, supervisors, and agency directors from around the globe receiving in-depth training in feedback-informed practice.  It was a phenomenal experience.  As the video below shows, we worked and played hard!

Already, people are signing up for the next “Advanced Intensive” scheduled for the third week of March 2013 and the new three-day intensive training on FIT supervision scheduled for the 6-9th of August 2013.   Both events follow and are designed to complement the newly released ICCE FIT Treatment and Training Manuals.  In fact, all participants receive copies of the 6 manuals, covering every detail of FIT practice, from the empirical evidence to implementation.  The manuals were developed and submitted to support ICCE’s submission of FIT to the National Registry of Evidence Based Practices (NREPP).  As I blogged about last March, ICCE trainings fill up early.  Register today and get the early bird discount.

The International Center for Clinical Excellence: Using Social Networks for "Real Time" Research

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The International Center for Clinical Excellence was officially lauched at the Evolution of Psychotherapy Conference in December 2009.  Since that time, membership has grown steadily.  With over 3800 members, the ICCE is the largest, web-based community of behavioral health professionals dedicated to improving the quality and outcome of service delivery.  The site features nearly a hundred discussion forums, taking place in a number of languages, on topics specific to treatment and research.

Many agencies and systems of care are using the site to coordinate implementation of feedback-informed treatment.  Of course, those attending ICCE training events (e.g., the Advanced Intensive, Training of Trainers, and Achieving Clinical Excellence conference), use the site for both pre and post training support and continuing education.

And now, the site is being used for a new purpose: research.  ICCE member and associate Wendy Amey was the first.  She used the site successfully for her dissertation, surveying members about how they work with trauma.  I am pleased to announce two new research projects that will access the ICCE community.

The first is being conducted by McGill University counseling psychology doctoral candidate Ionita Gabriela.  Her study focuses on clinicians’ experiences with using measures to monitor client progress in the services they offer.  Implementation is the challenge most clinician and agencies face when incorporating routine outcome monitoring into practice.  All participants will be entered into a drawing for a $100 Amazon gift certificate.  More importantly, participants will contribute to the expanding knowledge base on feedback informed treatment.  Whether or not you are a member of ICCE, you can contribute by taking part in the study.  Click here to send an email to Ionita to complete the interview (it only takes about 15 minutes).

The second study is being conducted by me and ICCE Associate Daryl Chow as part of ICCE’s continuing emphasis on clinical excellence.  The study builds on groundbreaking research by Ronnestad and Orlinksy on the subject of therapist development.  Particpants are asked to complete a brief (8-12 minutes), online survey with questions pertaining to your development as a clinician.   All participants will be entered into a drawing, the winner receiving all 6 of the newly released FIT Treatment and Training Manuals (valued at $100).  Again, you can participant whether or not you are currently a member of the ICCE.  In fact, please ask your colleagues to participate as well!  Click here to complete the secure, online survey (no identifying information will be sought).

More from Sweden

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sweden-mapThree short weeks ago, I was in Stockholm, Sweden talking about “what works” in clinical practice.  As I announced at the time, my visit coincided with an announcement by the organization governing mental health practice in the country.  For the better part of a decade, CBT enjoyed near exclusive status as “evidence-based.”  Indeed, payment for training of clinicians and treatment of clients in other approaches disappeared as over two billion Swedish crowns were spent on in CBT. 

The result? The widespread adoption of the method had no effect whatsoever on the outcome of people disabled by depression and anxiety.  The conclusion?  Guidelines for clinical practice were reviewed and expanded.  Research on feedback is in full swing in the largest randomized clinical trial on FIT in history.

More news…

Today, I received notice from Swedish clinician and publisher, Bengt Weine, that my article, “The Road to Mastery” (written together with my long friend and collaborator, Mark A. Hubble, Ph.D.), had been translated into Swedish and accepted for publication in SFT, the Swedish Family Therapy journal.  If you understand the language, click here to access a copy.

Helping clinicians and agencies along the “road to mastery” is what the upcoming Advanced Intensive and Training of Trainers events are all about.  Join colleagues from around the globe for these fun, intense days of training in Chicago.

A Handy "Little Helper" for the Outcome Rating Scale: A Freebie from the ACE Conference Committee

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This last week the planning committee for the upcoming Achieving Clinical Excellence (ACE) conference meet once again in Horsholm, Denmark.  In the picture from left to right: Liz Plutt, Bill Andrews, myself, Rick Plutt (Conference Chair), and Bogdan Ion.  Taking the photo was Susanne Bargmann.

The agenda for the three day event is now set: (1) one day pre-conference on feedback informed treatment (FIT); (2) two days of plenaries and presentations by an international group of clinicians, researchers, and educators.

On day one, the conference kicks off with a keynote address by the world’s “expert on expertise,” Dr. K. Anders Ericsson.  Throughout the day, other speakers will translate Dr. Ericsson’s research into practical steps for enhancing the performance of mental health professionals, agencies, and systems of care.

Day two kicks off with a keynote address by Dr. Robbie Wagner addressing the question, “what barriers stand in the way of improving our effectiveness?”  Once again, the rest of the day will be spent identifying solutions for the problems standing in the way of expertise and expert performance.

We still have several openings for presentations at the conference.  If you have experiences or data related to: (1) measuring outcomes; (2) implementing feedback informed treatment; (3) the qualities of super effective clinicians or treatment approaches, then PLEASE click go to the ICCE website and submit a description for consideration.

It’ll be a fun, inspiring, and rewarding three days in Amsterdam.  Don’t miss it!  Register today and get the early bird special, saving you 100’s of dollars!

In the meantime, click on the link below to download a handy little tool for scoring the Outcome and Session Rating Scales.  It’s a combination bookmark and 10 centimeter ruler.

Ace Ruler (PDF Format)

NEWSFLASH: The Advanced Intensive and Training of Trainers in Feedback Informed Therapy (FIT)

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Dateline: March 17th, 2012, Chicago, Illinois USA

Barely a month ago, I announced the addition of a second “Advanced Intensive” (AI) course in Feedback Informed Treatment (FIT).  The original March training filled really early this year and a long waiting list formed.  Now the second Advanced Intensive training in FIT scheduled for July 30th through August 1st is nearly full.  Register now and you can still receive the early bird price.  Additionally, we’re offering a super special discount for people attending both the AI and the ICCE Training of Trainers.  Don’t wait though, only a handful of spaces remain.  If you would like to attend both courses, drop me an email straight away and I’ll send you the special registration code.

We look forward to meeting everyone attending the AI this week.  Stay tuned for tweets and video from the training.

 

The Achieving Clinical Excellence Conference CALL FOR PAPERS

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In October 2010, the first annual “Achieving Clinical Excellence” was held in Kansas City, Missouri.  A capacity crowd joined leading experts on the subject of top performance for three days worth of training and inspiration.  K. Anders Ericsson reviewed his groundbreaking research, popularized by Malcolm Gladwell and others.  ICCE Director, Scott D. Miller translated the research into speciific steps for improving clinical performance.  Finally, classical piansts David Helfgott, Rachel Hsu, and Roger Chen, demonstrated what can be accomplished when such evidence-based strategies are applied to the process of learning specific skills.

The ICCE is proud to announce the 2nd “ACE” conference to be held May 16th-18th, 2013 in Amsterdam, Holland.  Join us for three educational, inspiring, and fun-filled days.  Register today and receive a significant “Early Bird” discount.  The ACE conference committee is also issuing an international “Call for Papers.”  If you, your agency, or practice are committed to excellence, using outcomes to inform practice, or have published research on the subject, please visit the conference website to submit a proposal.

Here’s what attendees said about the last event:

Implementation Science, FIT, and the Training of Trainers

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The International Center for Clinical Excellence (ICCE) is pleased to announce the 6th annual Training of Trainers event to be held in Chicago, Illinois August 6th-10th, 2012.  As always, the ICCE TOT prepares participants provide training, consultation, and supervision to therapists, agencies, and healthcare systems in Feedback-Informed Treatment (FIT).  Attendees leave the intensive, hands-on training with detailed knowledge and skills for:

  1. Training clinicians in the Core Competencies of Feedback Informed Treatment (FIT/CDOI);
  2. Using FIT in supervision;
  3. Methods and practices for implementing FIT in agencies, group practices, and healthcare settings;.
  4. Conducting top training sessions, learning and mastery exercises, and transformational presentations.

Multiple randomized clinical trials document that implementing FIT leads to improved outcomes and retention rates while simultanesouly decreasing the cost of services.

This year’s “state of the art” faculty include: ICCE Director, Scott D. Miller, Ph.D., ICCE Training Director, Julie Tilsen, Ph.D., and special guest lecturer and ICCE Coordinator of Professional Development, Cynthia Maeschalck, M.A.

Scott Miller (Evolution 2014)

tilsencynthia-maeschalckJoin colleagues from around the world who are working to improve the quality and outcome of behavioral healthcare via the use of ongoing feedback. Space is limited.  Click here to register online today.  Last year, one participants said the training was, “truly masterful.  Seeing the connection between everything that has been orchestrated leaves me amazed at the thought, preparation, and talent that has cone into this training.”  Here’s what others had to say:

 

The New Average: Meeting the Need to Exceed

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No matter where you look,good is no longer “good enough.”  In a recent article in the New York Times, author and trend watcher, Thomas L. Friedman, declared, “Average is Over.”  It’s an argument similar to the one made over a decade ago by Robert Reich, former Secretary of Labor under Bill Clinton, in his phenomenally prescient book The Future of Success.  I read it at the time with a mixture of apprehension and anticipation.  Globalization and advances in information technology were then and are now challenging the status quo.  At one time, being average enabled one to live an average life, live in an average neighborhood and, most importantly, earn an average living.  Not so anymore.

Average is now plentiful, easily accessible, and cheap.  What technology can’t do in either an average or better way, a younger, less-trained but equally effective provider can do for less. A variety of computer programs and web-based systems provide both psychological advice and treatment.  (By the way, studies to date document outcomes equal to face-to-face services for at least the most common mental health related issues).  At the same time, as reviewed here previously on this blog, the evidence again and again shows no difference in outcome between professionally trained clinicians and students or paraprofessionals.  Uh-oh.

What is the solution?  Friedman says, “everyone needs to find their extra–their unique value contribution that makes them stand out in whatever is their field.”  Yeah, exactly.  As my father used to say, “Do your best and then a little better.  What can behavioral health professionals do to stand out?  Well, if you are trained, licensed or certified, practicing evidence-based, know the latest methods and research findings, and understand how the brain works, then you are, in a word, average.  Going forward, standing out will require evidence that you are effective; measures documenting not only who you help but identifying those you do not.  Professional development will be less about learning a new method than documenting what you do to “do your best and then a little better.”

Helping clincians stand out is what the ICCE is all about.  Everyday, thousands meet online to learn, share, and support each other in both measuring and improving the impact of their clinical work.  Each year, the ICCE offers two intensive training opportunities: The Advanced Intensive and the Training of Trainers.  Both events are designed to help professionals achieve their personal best.  The Training of Trainers is specifically designed for participants, such as supervisors, managers, and agency directors, who wish to train others or transform public or private agencies for achieving success.   The Advanced Intensive scheduled for March is sold out.  By popular demand, we are offering an unprecedented second opportunity to attend the Advanced Intensive this summer.  Don’t wait to register.  Despite only announcing this event last week, half of the seats are already booked.  Either event will insure that you have the tools and skills necessary to meet the need to exceed.  Email us with any questions at: training@centerforclinicalexcellence.com.

(By the way, if you are interested, you catch watch a clip of Friedman delivering his message to the Hudson Society here).

Getting FIT: Another Opportunity

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The March Advanced Intensive in Feedback Informed Treatment is full!  Not a single space left.  For several weeks, we put folks on a waiting list.  When that reached nearly 20, we told most they’d probably have to wait until next year to attend.

Wait no more!

The ICCE is pleased to announce a second, “Advanced Intensive” Training schedule for July 30th through August 2nd, 2012 in Chicago, IL, USA.  If you’ve read the books and attended a one or two day introductory workshop and want to delve deeper in your understanding and use of the principles and practices of FIT, this is the training for you!  Multiple randomized clinical trials document that FIT improves outcomes and retention rates while decreasing costs of behavioral health.

Four intensive days focused on skill development. Participants will receive a thorough grounding in:

  • The empirical foundations of FIT (i.e., research supporting the common factors, outcome and alliance measures, and feedback)
  • Alliance building skills that cut across different therapeutic orientations and diverse client populations
  • How to use outcome management tools (including one or more of the following: ORS, SRS, CORE, and OQ 45 to inform and improve treatment)
  • How to determine your overall clinical success rates
  • How to significantly improve your outcome and retention rate via feedback and deliberate practice
  • How to use technology for support and improvement of the services you offer clients and payers
  • How to implement FIT in your setting or agency

The training venue is situated along the beautiful “Magnificent Mile,” near Northwestern hospital, atop a beautiful tall building steps from the best retail therapy and jazz clubs in Chicago. As always, the conference features continental breakfast every morning, a night of Blues at one of Scott’s favorite haunts and dinner at arguably the best Italian restaurant in Chicago.

Unlike any other training, the ICCE “Advanced Intensive” offers both pre and post attendance support to enhance learning and retention.  All participants are provided with memberships to the ICCE Trainers Forum where they can interact with the course instructors and participants, download coarse readings, view “how-to” videos, and reach out to and learn from the thousands of other member-clinicians around the world.

Don’t wait.  Register today here.

If you are interested in hanging out in Chicago a few extra days, why not register for both the “Advanced Intensive” and the 2012 “Training of Trainers” workshop?  Thanks to the demand, for the first time ever, the two events are being held back to back. Sign up for both events by May 31st and receive 25% off for the trainings!  To obtain your discount code for both events, email: events@centerforclinicalexcellence.com today.

Excellence "Front and Center" at the Psychotherapy Networker Conference

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This year, the Psychotherapy Networker is celebrating it’s 35th anniversary.  I’m not going to let on how long I’ve been a reader and subscriber, but I can say that I eagerly anticipate each issue.  Rich Simon and his incredibly dedicated and talented crew always seem to have their fingers on the pulse of the profession.

It is no accident that our most recent work on achieving excellence in behavioral health appeared in the pages of the Networker–in 2007, our study of top performing clinicians, “Supershrinks,” and then last year, “The Road to Mastery” which layed out the most recent findings as well as identified the resources necessary for the development of therapeutic expertise.

I was deeply honored when Rich Simon asked me to give one of the plenary addresses at this year’s Networker Symposium, March 22-25th, 2012.  The theme of this year’s event is, “Creating a New Wisdom: The Art and Science of Optimal Well Being” and I’ll be delivering Friday’s luncheon address on applying the science of expertise to the world of clinical practice.

Click here to register online and join me for 3 fantastic days at this historic meeting.